Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marlette Community Hospital Ltcu during CMS and state inspections, most recent first.
Improper food labeling, dating, and storage were observed in the kitchen and coolers. Opened foods such as rice, pepperonis, frozen vegetables, dry goods, prepared cottage cheese, sandwiches, Jello, yogurt, and other items lacked required labels or dates, and cooked bacon was stored on the same rack as clean cookie sheets. The milk cooler was at 45 degrees, and an expired roast beef was later found in the walk-in cooler.
Infection Control Program and Water Management Deficiencies: The DON, who served as the infection preventionist, stated that infections were not being mapped and that monthly IPC audits were not consistently completed; hand hygiene audits had been stopped, the last PPE audit was in February 2025, and no audits for the laundry area or kitchen were observed since the last survey. The facility also lacked an active legionella/OPPP control process, as the water softener drain line was observed without an air gap and staff stated chlorine residual was not tested on site.
A resident with severe cognitive impairment and diagnoses including Alzheimer’s disease, anxiety, and residual schizophrenia had a PRN Ativan order for anxiety and before showers that lacked a stop date or review date. The psychiatry note continued the order without documenting a specific duration, and the DON acknowledged the order still had no end or review date despite the facility policy limiting PRN psychotropic orders to 14 days unless the prescriber documents the rationale for extension.
Failure to develop a baseline care plan for oxygen administration. A resident with chronic respiratory failure with hypoxia, CHF, and pulmonary fibrosis was receiving O2 via nasal cannula and reported needing 7 LPM, but the chart lacked a baseline care plan for oxygen after admission. The DON acknowledged the baseline care plan was not in the electronic charting, even though the resident was receiving O2 therapy on admission and the facility policy required a baseline care plan within 48 hours.
Failure to Provide Routine Dental Services: A resident admitted with multiple chronic diagnoses was observed without upper teeth and stated her upper dentures were left at home because they do not fit. She was unsure whether she had been seen by the dentist and said she wanted to be seen. Record review showed an order for dental services, but the resident had not been placed on the dental list since admission; SW and the DON acknowledged the oversight.
The facility was found to have multiple food safety and sanitation deficiencies, including failure to date mark potentially hazardous foods, maintain clean equipment, and ensure proper glove use and handwashing. These issues were observed during a kitchen inspection and lunch service, posing an increased risk of foodborne illness to residents.
The facility reported a medication error rate of 14.7% due to late administration and improper documentation by RNs. Medications were administered outside the scheduled time frame, and documentation was inaccurately completed. Additionally, infection control practices were not followed, as observed with a nurse using bare fingers to handle medications. The DON confirmed these actions were against facility policies.
The facility failed to properly store and label medications, including insulin pens and eye drops, which were found opened and undated in medication carts. A nurse attempted to store a resident's declined medications for later use, contrary to policy, and disposed of them improperly. Non-medication items were also stored with medications, violating facility policies.
A facility failed to properly track and document COVID-19 vaccinations for four residents, leading to a deficiency. The residents were not offered the updated 2023-2024 vaccine, and there was no documentation of education on the vaccine's benefits and risks. The facility's policy requires such documentation, but it was missing, potentially leaving residents uninformed and unvaccinated.
A facility failed to monitor a resident's change in condition according to professional standards, leading to potential delayed treatment. The resident, with severe cognitive impairment and heart-related diagnoses, was hospitalized for exacerbated heart failure and pulmonary edema. Despite symptoms like shortness of breath, the facility did not document respiratory assessments during the critical period, as confirmed by the DON.
A facility failed to assist a resident with a prosthetic device, as the resident was observed without the bottom portion of his prosthesis due to it being broken. The issue was not documented, and the orthotist was not informed for repairs. The resident's care plan required wearing the prosthesis daily, but the facility's rehabilitation procedures were not followed, resulting in inadequate care.
Improper Food Labeling, Dating, and Storage
Penalty
Summary
Food items in the kitchen were observed improperly labeled, dated, and stored during the initial kitchen tour. On the prep table, a large plastic container held an open blue bag of rice with no label, open date, or expiration date, and the dietary supervisor acknowledged the missing dating and labeling. In the walk-in freezer, two large opened baggies of pepperonis had no open or expiration dating and were stored near sealed pepperonis, and an open bag of frozen sugar snap peas was closed with a rubber band and also had no open date. In dry storage, a box of cream of wheat and a box of pancake mix were both open in plastic bags without open or expiration dates. The flip-top cooler holding individual milk cartons was at 45 degrees, and the dietary supervisor stated it should be well under 40 degrees after discussing the issue with kitchen staff. Additional observations showed prepared foods and other items stored without required dating or with improper storage. In a short cooler, individual cups of cottage cheese and wrapped sandwiches were prepared for resident trays but had no labels, dates made, or expiration dates, and kitchen staff stated they were not labeled because they were going to be used. In a stand-up cooler, individual cups of Jello and yogurt were also present without preparation or expiration dates, which the dietary supervisor verbally acknowledged. On the dry cookie sheet tray storage rack, two pans of cooked bacon were stored on the same rack as clean cookie sheets, and the dietary supervisor stated they should not have been there. In the café stand-up freezer, an open bag of frozen food was unidentifiable until the CDM identified it as possibly chicken strips and then onion rings; the item was discarded. Record review showed the facility policy required foods to be covered, dated, labeled with common names when not readily recognizable, and discarded within required timeframes, and the facility later found expired roast beef in the walk-in cooler with a use-by date of 8/2/25.
Infection Control Program and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain a comprehensive infection control program because monthly infection control reports did not include mapping of infections and only minimal audits were being completed. During interview, the DON, who served as the infection preventionist, stated that infections were not being mapped on the halls and described this as an oversight. The DON also stated that monthly audits were not consistently performed, that hand hygiene audits had been stopped because staff had been doing well, that call-in slips were reviewed for trends, and that the last PPE audit had been completed in February 2025. No evidence of audits for the laundry area or kitchen was observed since the last survey. The facility also failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During an environmental tour, the water softener drain line was observed sitting directly inside the drain instead of having an air gap of at least one inch. The Director of Maintenance stated that chlorine residual was not tested on site, and the Facilities Supervisor stated that the city did not use chlorine in the water. The Water Quality Report from the city listed guidelines for maximum contaminant disinfectant level but did not list chlorine residual results, while the facility's Water Management Plan stated that chlorine would be used as a disinfectant and that water samples would be collected and monitored quarterly.
PRN Ativan Order Continued Without Required Review or Stop Date
Penalty
Summary
The facility failed to evaluate and document the clinical rationale for continuing a PRN anti-anxiety medication beyond 14 days and failed to identify a stop date for one resident’s Ativan order. The resident had a quarterly MDS showing a BIMS score of 2, indicating severe cognitive impairment, and diagnoses including Alzheimer’s disease, COPD, anxiety, residual schizophrenia, ASHD, and colon cancer. The physician order dated 04/09/2025 was for Ativan 0.5 mg by mouth daily PRN for anxiety, may give 1/2 hour prior to showers, and the order did not include a stop date or review date. The latest psychiatry note dated 6/25/25 stated the Ativan order remained unchanged and still had no end date or next review noted. The note’s medication section listed the active order as Ativan 5 mg, take 1 tab, status unchanged, while the assessment and plan stated to continue Ativan 0.5 mg; the note was reconciled by NP G. During interview on 8/6/25, the DON stated the resident mainly received the PRN on shower days and acknowledged the chart contained an addendum about the dose discrepancy, but also acknowledged there was still no end or review date to the Ativan order. The facility policy identified anti-anxiety medications as psychotropics and stated PRN psychotropic orders, excluding antipsychotics, are limited to no more than 14 days unless the prescriber documents the rationale for extending the order and a specific duration.
Failure to Develop Baseline Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to develop a baseline care plan for one resident, R25, within 48 hours of admission. R25 was admitted with diagnoses including chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, congestive heart failure, and pulmonary fibrosis. On 08/06/2025 at 8:56 AM, R25 was observed sitting in bed receiving oxygen via nasal cannula and stated that she usually receives 7 liters per minute (LPM) of oxygen, but because of different tubing she was now receiving 8 LPM and her oxygen saturation was not nearly as high as usual. Record review later showed a physician order for oxygen at 7 LPM dated 7/24/25. Review of the care plans showed that a care plan for oxygen use was not developed until 8/6/25, and no baseline care plan was present for oxygen after the resident’s admission. The MDS assessment dated [DATE] indicated the resident was receiving oxygen therapy on admission. During interview, the DON stated that a baseline care plan should have been in the electronic charting and acknowledged that the resident was on 7 LPM, varying from 7 to 10 LPM in the hospital, but there was no baseline care plan in the electronic charting. The facility policy titled MRH Baseline Care Plan stated that a baseline care plan will be established and implemented for each resident within 48 hours of admission and will include instructions needed to provide effective and person-centered care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who was admitted with diagnoses including malignant neoplasm of the pancreas, neuropathy, type 2 diabetes, and hypertension. During observation, the resident was noted to have no upper teeth, with lower teeth visible, and stated that she had left her upper dentures at home because they do not fit. She also stated that she was not sure whether she had been seen by the dentist in the facility, but that she would like to be seen. The resident stated that she would like to eat more salads but could not eat them because she did not have her upper dentures. Social work interview and record review showed that the resident had an order for dental services dated 11/19/2024, but the resident had not been seen by dental since admission. The social worker stated the resident had not been placed on the list to be seen by the dentist and identified this as an oversight. The DON also stated that the resident should have been seen by the dentist by now. The facility policy stated that routine and emergency dental services are available and that the nurse supervisor or designee is responsible to notify social work or designee of a resident's need for dental services.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols, as evidenced by several observations during a kitchen inspection. An opened bag of hard-boiled eggs and a chicken wrap in the deli cooler were found without date marks, which is a violation of the 2017 FDA Food Code Section 3-501.17. This section mandates that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with a discard date. Additionally, encrusted food debris was found on a commercial mixer, contravening the FDA Food Code Section 4-601.11, which requires that food-contact surfaces be clean to sight and touch. During lunch service, improper glove use and handwashing practices were observed among dietary staff. One staff member picked up dropped silverware with gloved hands and continued to handle clean silverware without changing gloves or washing hands until prompted. Another staff member was seen adjusting their glasses with gloved hands while serving food, without changing gloves or washing hands afterward. These actions violate the FDA Food Code Sections 3-304.15 and 2-301.14, which stipulate that single-use gloves should be discarded when soiled and that hands should be washed after contamination.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 14.7% due to five medication errors out of 34 opportunities. Registered Nurse (RN) A was observed administering medications late to multiple residents, with documentation indicating administration times well beyond the scheduled times. For instance, medications for one resident were documented as administered over an hour late, and another resident's medications were documented as administered by RN A despite being handed off to RN B for administration. Additionally, RN A split the administration of a resident's medications into two separate times, both outside the scheduled window. Further deficiencies were observed with RN B, who failed to document the time of removal of Morphine Sulfate from the controlled substance box on the proof of use form, contrary to facility policy. RN C was observed using improper infection control practices by using bare, ungloved fingers to handle medication crushing pouches and capsules. The Director of Nursing confirmed that these practices were against the facility's standards and policies, which require medications to be administered within a specific time frame and proper documentation and hygiene practices to be followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and dispose of medications, as well as ensure that insulin pens and eye drops were labeled with dates when opened. During an observation, a registered nurse (RN) attempted to administer medications to a resident who declined them because she was on the phone. The RN returned the medications to the cart, intending to label the cup with the resident's initials and store it for later use, which was against the facility's policy. The Director of Nursing (DON) intervened, instructing the RN to dispose of the medications properly, but the RN disposed of them in a Sharps container instead of using the designated solution for medication disposal. Further inspection of the medication carts revealed additional issues. One cart contained four insulin pens that were opened and undated, with three prescribed for the same resident. Another cart had two prescription eye drops and two insulin pens that were also opened and undated. Additionally, non-medication items such as pens and markers were stored in the same drawer as oral medications. The DON confirmed that insulin pens and eye drops should be dated when opened, and non-medication items should not be stored with medications, as per the facility's policies.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to implement proper tracking and documentation of COVID-19 immunizations for four residents, resulting in a deficiency. The report highlights that residents were not offered the updated 2023-2024 COVID-19 vaccine, and there was no documentation of education provided regarding the benefits and risks of the vaccine. Specifically, Resident #13, #17, #30, and #35 had incomplete records in their electronic medical records (EMR) regarding their vaccination status. For instance, Resident #13's most recent vaccination was documented in 2022, with no record of being offered the updated vaccine or any signed declination. Similar issues were found with the other residents, with some having no documented immunization at all. The facility's Infection Preventionist and Director of Nursing confirmed the lack of documentation after reviewing the EMR and paper charts. The facility's policy requires that education be provided to residents or their representatives before offering the vaccine, and that documentation should include education provided, reasons for non-vaccination, and any signed declinations. The absence of such documentation indicates a failure to adhere to these policies, potentially leaving residents uninformed and unvaccinated, as per the CDC guidance for the updated COVID-19 vaccine.
Failure to Monitor Change in Condition
Penalty
Summary
The facility failed to appropriately monitor a resident for a change in condition according to professional standards of practice, which resulted in the potential for delayed treatment and further deterioration of the resident's condition. The resident, who had severe cognitive impairment and multiple diagnoses including hypertensive heart disease with heart failure, aortic valve stenosis, peripheral vascular disease, hypertension, and dementia, was observed using supplemental oxygen but was unable to recall when or why it was needed. The resident had been hospitalized for exacerbation of congestive heart failure and acute pulmonary edema and returned to the facility after treatment. The resident's electronic medical record revealed a series of events leading up to the hospitalization, including reports of shortness of breath and abnormal lung sounds. Despite these symptoms, there was a lack of documented respiratory assessments corresponding to the administration of PRN medication and during the period of acute change in condition. The resident's vital signs were monitored daily, but only one oxygen saturation result was documented per day, and no comprehensive respiratory assessments were recorded from the time of the initial change in condition until the resident was found in respiratory distress and transferred to the emergency department. The Director of Nursing confirmed the absence of respiratory assessments in the resident's records during the critical period. The DON stated that a full respiratory assessment, including lung sounds and resident appearance, should have been documented during episodes of acute change in condition until the resident returned to baseline. Additionally, a respiratory assessment should have been documented to correspond with the administration of PRN guaifenesin. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.
Failure to Assist Resident with Prosthetic Device
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthetic device, specifically for a resident who had lost most of his right arm in an accident. The resident was observed multiple times without wearing the bottom portion of his prosthesis, and he mentioned that some CNAs were unable to put it on. It was revealed that the prosthesis was broken, and the orthotist had not been contacted for repairs. The Director of Nursing was unaware of the issue, and the Physical Therapist acknowledged that the matter had been overlooked after being informed by a CNA weeks prior. The resident's electronic medical record indicated a diagnosis of acquired absence of the right upper limb below the elbow and the presence of an artificial right arm. Physician orders required the resident to wear the prosthetic arm for at least 2 hours a day, 6-7 days a week. The care plan included assistance with the prosthesis and alerting occupational therapy if issues arose. However, the facility's policy on rehabilitation procedures was not followed, as the prosthesis remained unrepaired and undocumented, leading to the resident not receiving the necessary assistance and care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marlette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanilac Medical Care Facility | 14.1 mi | ★★★★★ | 12 | 0 |
| Fisher Senior Care And Rehabilitation | 14.4 mi | ★★★★★ | 8 | 0 |
| Tuscola County Medical Care Facility | 19.4 mi | ★★★★★ | 11 | 0 |
| Medilodge Of Cass City | 19.7 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Yale | 20.2 mi | ★★★★★ | 0 | 0 |
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